Evaluation of Acute Abdominal Pain

Dr. Napoleon B. Alcedo February 17, 2011

Surgery – PPT, 2012B trans  responds to irritation from infectious or other

Surgery – Audio Recording inflammatory processes
Surgery – Medicine I Lecture on Adbominal Pain, Bates Guide to PE or  can also be chemical
Harrison’s Principle of IM  Hydrochloric Acid (HCl) type of pain – px is awakened
and can tell exactly what time the pain starts by the
Acute Abdominal Pain minute (usually intensity 9-10/10) in perforated ulcer
 Pain with onset less than 6 hours  Lateralization of the discomfort is possible since only one side of
 When you suspect a case of an acute onset pain with a pain the nervous system innervates a given part of the parietal
scale of 7 out of 10, then it’s always a symptom of intra- peritoneum
abdominal disease. In the elderly and sometimes in children we  sharp and well-localized (can be pointed to by a finger)
encounter patients who do not experience symptoms except This is what you call “good morning appendicitis.” This means
the pain. that when you open the appendix, it will pop out.
 May present as an acute manifestation of a chronic dse like
chronic cholecystitis 3. Referred Pain - perceived distant from its source
 Acute and Severe Pain  results from convergence of nerve fibers at the spinal
cord
 almost always a symptom of intra-abdominal disease
 may be the only indicator for the need of a  e.g. scapular pain from biliary colic, shoulder pain
laparotomy from diaphragmatic irritation
 as in cases of acute intestinal ischemia [e.g. an elderly Neuroanatomic Basis of Referred Pain:
with a thrombus/embolus in the superior mesenteric
artery; even if the px did not note history of arrhythmia
and PE is normal (abdomen is soft) but presents with
acute and severe pain – vascular emergency]

Types of Pain
1. Visceral – your serosa is the visceral peritoneum in other
words visceral peritoneum comes from the abdominal
viscera/organs (as in cholecystitis, appendicitis, intestinal
obstruction, etc.)
 innervated by autonomic nerve fibers Visceral afferent fibers stimulated by irritation (A) synapse with second
 mainly due to sensation of distention and muscular order neuron in the spinal cord (B) as well as somatic fibers (C) arising
contraction from the left shoulder area (Cervical roots 3 to 5 and the brain
 vague interprets the pain to be somatic in origin and localizes it to the
 nauseating – because of distention and reflex ileus caused shoulder)
by the inflammation in the abdomen; px feels full and E.g. Kehr’s sign shoulder pain in a patient with subphrenic hematoma
sometimes vomits or splenic rupture
 poorly localized
 perceived in areas corresponding to embryonic origin  Reminder: Palpation should be performed LAST in a patient with
of affected structure abdominal pain. Go first with the history like:
 Pain in periumbilical area – involves the medial structures  type of pain
(jejunum, ileum, appendix, proximal colon, up to the proximal  Is it sharp or constricting?
transverse colon – supplied by the superior mesenteric artery)  If it is constricting, it is a spastic pain in the body’s
 Lower abdomen/hindgut structures – distal transverse colon up attempt to pass something through an obstruction
to the anus; also includes the genitourinary tract (that’s why a (colicky – sudden and severe).
renal colic is usually felt in the lower abdomen)  An example is a biliary colic (patient takes in a fatty
2. Somatic – comes from the parietal peritoneum meal → stimulates gallbladder to contract →
 Felt when an inflamed abdominal structure comes in contact gallbladder contracts against the biliary tree which is
with the anterior abdominal wall which is innervated by obstructed by stone → pain)
somatic nerves of parietal peritoneum.
 The dermatomal levels come into play. The innervations of
parietal peritoneum follow the dermatomal level.
E.g., the dermatomal level of umbilicus is T10.

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 PATIENT HISTORY
Abdominal Pain Character: Type of Onset of Pain
 Acute wave of sharp, constricting pain – renal or biliary
colic
 because the hollow viscous is attempting to get rid of the
obstruction
 If you have ureteral stone and your body wants to get rid of
that ureteral stone and pushing it towards your bladder, the A – many causes of abdominal pains subsides spontaneously with time
onset of the pain is severe and very acute. It’s sharp and very (acute GE)
painful. The patient could go to neurogenic shock B – colicky – progresses and remits over time (intestinal, biliary and renal
 waves of dull pain with vomiting – intestinal obstruction colic) time course varies from minutes, hours, days or weeks
 vomiting is NOT always present INITIALLY C – progressive (AP/diverticulitis)
 it depends on the site and degree of obstruction (the more D – catastrophic (ruptured AAA)
proximal the obstruction, the earlier the onset of vomiting)
 colicky pain which is on and off and then becomes steady Pain Location and Radiation
strangulating intestinal obstruction, mesenteric ischemia  Upper Abdominal Pain
 appendicitis  Foregut structures: stomach, liver, duodenum, pancreas
 the appendix tries to remove the obstruction by
contraction → pain  Peri-umbilical Pain
 an ischemic type of pain (continuous and steady)  Midgut structures: small bowel, proximal colon,
 Phases: appendix
1. congestive phase  Lower Abdominal Pain
2. suppurative phase [appendix loses the ability to  Hindgut structures: distal colon, genito-urinary tract
contract because the nerves become devascularized]  Right or Left Lower Quadrant Pain
3. gangrenous phase
 abdominal or psoas abscess
 strangulating Intestinal obstruction
 abdominal wall hematomas
 That’s why if you have a patient that you are suspecting
to have an intestinal obstruction and it was confirmed by  endometriosis, Pelvic Inflammatory Disease (PID), torsion
imaging studies, do not wait for the onset of steady pain. of ovary
Because if you wait for the intestine to become ischemic  PID is initially is NON-surgical and managed medically,
then you will not be able to save the intestine and you only when it becomes complicated (development of a tubo-
have to resect that intestine in contrast to early ovarian abscess) that it is considered surgical
intervention where you dissect the adhesive intestine and  incarcerated or strangulated hernia
hopefully there will be reperfusion of the bowel and you  inflammatory bowel disease, renal stone
will be able to save abdomen.  Mittelschmerz
 Patient initially complains of wavelike colicky pain (pain  discomfort at the time of ovulation
is NOT continuous; pain is felt again if the intestine tries  may be due to rapid expansion of the dominant follicle,
to propel its contents against an obstruction; once the although it may also be caused by peritoneal irritation by
bowel relaxes, the pain disappears slowly) follicular fluid released at the time of ovulation.
 metallic tinkles during an acute attack – “peristaltic rush”
 ruptured ectopic pregnancy
 if no intervention is done, then LATER it becomes a
strangulated intestinal obstruction producing ischemia
thus continuous pain
 if the bowel perforates, “succus intericus” (intestinal juice)
leaks leads generalized peritonitis (constant pain;
patients lies still to ease the pain; pain aggravated by
movement)
 mesenteric ischemia
 A patient experiencing colicky pain, in contrast to
generalized peritonitis, would frequently change position.
 sharp constant pain worsened by movement
 (generalized) peritonitis
 tenderness all over the abdomen with involuntary (true
type) muscle guarding which is characterized by a rigid
abdomen
 tearing pain – in dissecting aneurysm usually in the elderly
 dull ache – in appendicitis, diverticulitis, pyelonephritis

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  Diffuse abdominal pain is visceral pain.  cardiovascular disease especially with arrythmia
 Surgical Abdomen – usually presents INITIALLY as abdominal  consider mesenteric ischemia, abdominal aortic
pain; If the px presents initially with vomiting, aneurysm, referred cardiac ischemic pain presenting
cough/colds/fever and then later abdominal pain, then most
probably it is NOT a surgical abdomen
with severe pain in the absent of symptoms
 Fever in appendicitis usually only develops during the  Diabetes Mellitus - ketoacidosis
suppurative or early gangrenous phase
 A patient with acute MI can NOT be operated on  HIV
 Lower lobe pneumonia can present as upper quadrant pain so  Inflammatory bowel disease
you must correlate this with history (cough, DOB, etc.)
Social History
Intensity
 tobacco abuse
 severe pain - perforated viscus, kidney stones,  consider mesenteric ischemia; nicotine can cause
peritonitis, pancreatitis, mesenteric ischemia vasospasm (Buerger‟s disease)
 pain out of proportion to physical examination findings  alcohol abuse
 mesenteric ischemia  consider pancreatitis, gallstone
 No muscle guarding, abdomen is soft, but complains of  skipping breakfast can also cause gallstones because the
severe pain. bile becomes more concentrated in the gallbladder during
 in the elderly, may be caused by an arrhythmia fasting
 medications, history of travel
Timing
 Sudden (“like a light switching on”)
PHYSICAL EXAMINATION
 perforated ulcer
 renal stone A. General Appearance
 ruptured ectopic pregnancy  acutely or chronically ill-appearing patient
 torsion of ovary or testis  malnourished patient
 ruptured aneurysms  positioning
 the blood oozing from the ruptured aneurysms will  retroperitoneal irritation – patient flexes
irritate the abdominal wall thus causing sudden pain
thighs to relax the psoas muscle
Associated Symptoms  peritonitis – patient lies very still
 bowel obstruction or nephrolithiasis – restless
 nausea and vomiting  biliary ascariasis – patient frequently moves
 usually precedes pain in non-surgical causes (“snake-like movement”)
 severe vomiting preceeding chest pain in esophageal  renal colic – restless patient
perforation (Boerhaave‟s)
 acute appendicitis and gastroenteritis – nausea and B. Back examination
vomiting happens after the onset of the pain  ecchymosis – in hemorrhagic pancreatitis
 fever
 anorexia C. Cardiopulmonary examination
 diarrhea or constipation – in sigmoid diverticulitis  assess for myocardial infarction
 bloody stool – in diverticulosis that became a  assess for cardiac arrhythmia
diverticulitis (inflamed diverticulosis)  arterial pulses – femoral pulse, pedal pulses
 dysuria – in nephrolithiasis
D. Abdominal Examination
Alleviating and Aggravating Factors 1. Observation
 relieved by antacids – Peptic Ulcer Disease (PUD)  distention
 aggravated by movement – peritonitis  generalized – sigmoid obstruction
 aggravated by fatty food intake – biliary tract disease  Distention becomes more marked in colonic than in
 The classic presentation of appendicitis is initially generalized small bowel obstruction
(or poorly localized periumbilical) abdominal pain, then after  asymmetry
a few hours, pain shifts to the RLQ. And this time, it is
associated with low-grade fever plus direct and rebound  peristalsis
tenderness.  Increased peristaltic waves of intestinal obstruction
 scars from previous abdominal surgeries, trauma
Past Medical History  hernia (signs of incarceration)
 history of abdominal surgery  reduced chest excursion (due to guarding)
 consider post-op adhesions causing obstruction
2. Auscultation
 most common cause of intestinal obstruction
 cholelithiasis  borborygmi – consider bowel obstruction
 surgery is done only when it becomes symptomatic  silent abdomen – consider a surgical abdomen
 diverticulitis
 can rupture, common in the elderly

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 3. Palpation IMAGING STUDIES
 do this after auscultation because it may alter the A. Directed Imaging
bowel sounds
B. Initial non-specific Radiologic Studies
 tenderness 1. chest x-ray detects:
 maximal tenderness – palpate LAST  to rule out perforated viscus
 Tenderness may originate in the abdominal wall. When  Identifies ~50-90% of perforated viscus
the patient raises the head and shoulders, this  Patient on left lateral decubitus/standing position
tenderness persists, whereas tenderness from a for 15mins
deeper lesion (protected by the tightened muscles)  If the air goes up to the liver and diaphragm, it is
decreases. positive for perforated viscus
 abdominal free air (pneumoperitoneum) below
 pulsatile masses – aneurysm the diaphragm
 abnormal fullness – mass or abscess  because a chest X-ray can visualize the dome of the
 muscle tone diaphragm better
 to differentiate between voluntary from involuntary  congestive heart failure
muscle guarding, palpate the left and right abdomen  pneumonia
simultaneously with both hands and compare the tone 2. KUB (kidney urinary bladder) x-ray to detect:
 voluntary guarding – if you ask the patient to
 small bowel obstruction
relax, then both sides would feel soft
 incarcerated hernia – seen as loops of bowel
 involuntary (true) guarding – there is a
difference in tone between the left and the  appendicitis – visualization of a fecalith
right abdominal area o it is non-compressible during KUB
 test for presence of peritoneal irritation  gallstone – calcium stones(radio-opaque)
 more severe than visceral tenderness  large bowel obstruction
 Generalized peritonitis causes exquisite tenderness  diverticulitis
throughout the abdomen, together with boardlike  volvulus
muscular rigidity 3. Second-line studies for unclear diagnosis
 should be done near the end of the  Abdominal CT scan
examination  Abdominal ultrasound
 CT Angiography – mesenteric ischemia
E. Genito-urinary Examination  Endoscopy – for obstruction
 examine for femoral hernia – located below the
inguinal ligament
 inguinal hernia – above the inguinal ligament Shoutouts:
 rectal exam on all patients with abdominal pain This trans is derived from the audio recording during the lecture and
 pain on palpation trans of Medicine2012B, we didn‟t consult Schwartz because we can‟t
 occult or frankly bloody stool find the specific topic on the book. As Dr. Alcedo told as at the end of
 pelvic exam for females the lecture, he would make his questions as practical as possible and
20-25points will be taken from this topic.
“As not only the disease interested the physician, but he was strongly
LABORATORY AND DIAGNOSTIC STUDIES moved to look into the character and qualities of the patient... He
deemed it essential, it would seem, to know the man, before
A. Urinalysis attempting to do him good.” - NATHANIEL HAWTHORNE (1804-
B. Complete Blood Count - leukocytosis may not always 1864)
appear “It is Nor permitted For The Sun To Catch Up
C. Electrocardiogram To The Moon;
D. Pulse Oximetry Nor Can The Night Outstrip The Day;
E. Serum Phosphate - increased in mesenteric ischemia Each just swims along in its own orbit(according to
F. Liver Function Tests law) (Quran 36;40)”
G. Blood cultures -FAISAL
H. Amylase
 Pancreatitis - (lipase preferred) “Maybe we like the pain. Maybe we're wired that way. Because without
 Bowel obstruction it, I don't know, maybe we just wouldn't feel real. What's that saying?
Why do I keep hitting myself with a hammer? Because it feels so good
 Bowel perforation or peptic ulceration when I stop.”
 Mesenteric Ischemia --- Grey’s Anatomy
I. Lipase indications
 pancreatitis Hi 2013A! Sorry for the late upload. I added some info from our Med
 bowel obstruction lectures, Harrison‟s and Bates para mas maintindihan yung ibang part
 duodenal ulcer and para may kaunting review na rin for Med I. Huling ire na lang!
J. Arterial Blood Gas Hehe. Kaya natin „to! 
 Mariel

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